Med Surg 3 Exam 2 Flashcards: Key Terms and Definitions

Preparing to help the patient to the bathroom

The nurse is caring for a patient with an open AAA repair who is 4 hours post op. Which action by the tech would require the nurse to intervene?

Bradycardia and Systolic HTN

The ICU is monitoring a pt. who has a traumatic brain injury for signs of ICP. Which would indicate an EARLY sign of deterioration in the patient' neurological status?

Check pedal pulses

Which of the following nursing interventions are appropriate in the immediate post op care of a patient with an endovascular graft repair of an AAA?

Nosebleed

Which of the following signs would cause the nurse to suspect a critically ill patient is developing DIC?

Administer vitamin K IM

The nurse is reviewing the HCP's orders for a patient with DIC. Which of the following orders should the nurse questions?

Lower the HOB

The nurse is caring for a client who has tetraplegia. When the nurse elevates the HOB to 30 degrees, patient complains of dizziness and becomes hypotensive. What should the nurse do?

CTA

The nurse is reviewing the diagnostic tests of a client admitted with a thoracic aneurysm. The client asks the nurse "How does the doctor know that this is an aneurysm?" The nurse knows that which of the following test results best confirms the diagnosis.?

"You will need to increase your diet high in potassium foods."

The charge nurse is observing a new RN providing discharge teaching for a client with HTN who is being prescribed Analapril. Which of the following comments by the new RN would prompt the charge nurse to intervene?

IV bolus of Atropine

The nurse on the cardiac unit is caring for a patient on telemetry who is recovering from a MI and has a hx of glaucoma. The patient's HR is 44. The nurse assesses the BP which is 98/60 and the patient is complain of dizziness and fatigue. The nurse notifies the provider and anticipates which of the following management strategies?

Cardiac tamponade

A client admitted with pericarditis calls the nurses station and complains of difficulty breathing and chest pain. The nurse assesses and reveals the vitals T-99.2, P-108, R-28, BP-106/94, O2 94%. The patient has jugular vein distention. Heart sounds are faint and lungs have faint crackles. The nurse recognizes that these symptoms are consistent with which of the following conditions?

Decorticate posturing

The nurse is caring for a client who is experiencing ICP. The nurse observes that the client's body becomes stiff withflexion of the upper extremities with extension and internal rotation of the lower extremities. How will the nurse document?

Eliminate grapefruit

What dietary modifications is priority for the nurse to include in teaching a patient who is taking Amlodipine to control their blood pressure?

Raise the knee gatch to make the client more comfortable

The nurse is assisting the tech during morning care of the client with a spinal cord injury at T5. Which of the following actions by the tech would require correction by the nurse?

Dyspnea may develop if the aneurysm dilates

The nurse is providing education to a client diagnosed with a small thoracic aneurysm. Which information should the nurse include in the teaching session?

QRS wave

The nurse is assisting with a cardioversion on a client with AFib. The nurse sets the defibrillator to synchronize the ECG on the monitor to make sure the electrical impulse discharge during which part of the patient's impulse cycle?

Liver function tests are needed regularly

A client with a spinal cord injury is having difficulty with muscle spasms and spasticity and the HCP orders dantrolene to manage the symptoms. Which of the following instructions are important for the nurse to inform the client about the drug?

It relaxes the heart and dilates the blood vessels

The physician prescribes amlodipine for a patient with HTN and a family hx of aneurysms. The patient asks the nurse how the medication works. How should the nurse respond?

I won't worry if I have a little swelling around my lips or face

The nurse is provided education to a client who has HTN and has a new prescription for Captopril. Which statement by the client would indicate that reinforcement is needed?

The pacemaker fires at a constant rate, not on demand

A cardiac ICU manager is reviewing types of pacemakers with a group of newly hired nurses. Which of the following statements by one of the nurses indicates the understanding of a fixed pacemaker?

2nd degree

The ICU nurse is checking the telemetry of a post-op patient who has displayed normal sinus rhythm. The nurse notes a recurrent pattern in which the patient's RE Interval has become progressively longer followed by a P Wave that is not conducted to the ventricles (No QRS). Which conduction problem would the nurse identify for the patient?

You need to check your pulse before taking this medication

A patient is being discharged on digoxin after being diagnosed with A Fib. When providing medication teaching, the nurse should include which of the following instructions?

5

The nurse is performing a Glascow Coma Scale assessment on a client who is unconscious. Which total score would indicate to the nurse that the patient probably has a severe brain injury?

Unequal pupils

The nurse is caring for a client with closed head injury who is emerging from a coma. Which o the following signs would prompt the nurse to notify the HCP immediately?

"I won't be able to drink alcohol while taking this medicine."

The nurse is teaching a client with a spinal cord injury who has a new prescription for Baclofen to treat muscle spasms. Which of the following statements by the client indicates an understanding of the teaching?

A systolic bruit

Which assessment finding would the nurse expect to find in a patient diagnosed with a AAA?

Lorazepam

The ICU nurse is caring for a pt. dx with a head injury who is intubated and becoming agitated and combative. The nurse prepares to administer which o the following medications to help the patient?

Enters at external jugular vein, ends at right ventricle

After a pt. receives a pacemaker, the pt. asks the nurse where the wires from the implanted transvenous pacing lead and pacemaker are located. The nurse explains based on the lead being in which of the following anatomical postitions?

Return to the ER if the client begins to have vomiting or slurred speech

A client is being discharged from the ER after suffering from a mild concussion. Which of the following discharge instructions should the nurse give the client's family member?

Epinephrine

The nurse is assisting with defibrillation for a patient with V Fib. After the first attempt is unsuccessful, which medication would the nurse anticipate giving before the next attempt?

Pericardiocentesis

You have a patient that is dx with cardiac tamponade. Which collaborative intervention would the nurse anticipate for the pt?

I will need a backup contraceptive method for my birth control pills

Phenytoin to prevent seizures related to brain injury. Which of the following statements by the client would indicate understanding of the teaching?

Absence of brain stem reflex

Coma

Apnea

SATA: The nurse is assisting in the clinical evaluation of a pt. who is a potential organ donor due to irreversible brain injury. Which of the following signs would indicate brain death of the pt.

Maintain bed rest with bedpan use

The ICU is caring for a pt. with a spinal cord injury who is incontinent. Which order from the HCP to manage the incontinent pt. should the nurse question?

A 77 year old with sepsis

An ICU nurse is teaching a newly licensed nurse about DIC. Which of the following clients would the nurse identify as having the highest risk for developing DIC?

Don't raise your arms above your head for 2 weeks

Tell MRI Techs if you have a pacemaker

Wear a medic alert ID

Keep cell phones on opposite sides

SATA: Which of the following should the nurse review with review with the client who is being discharged with a permanent pacemaker

Ensure ongoing nutritional support

Anticipate administration of an anticonvulsant

Monitor for Hyponatremia

SATA: The nurse is caring for a client following a TBI 5 days ago. Which of the following interventions will the nurse implements to prevent complications?

Mannitol

The ICU is caring for a patient with a TBI who develops cerebral edema. Which drug will the nurse expect to administer to the patient to decrease swelling?

Sedative at bedtime

A client has an 8cm enlarging AAA and is scheduled for surgery in the morning. Which of the following pre-op orders by the HCP should the nurse question?

Tell me more about why you feel the medication is not working?

It is important not to stop the medication suddenly at it may cause chest pain

SATA: A nurse is providing education to a client who is dx with HTN taking propranolol. The nurse determines that the client wants to stop taking the medication because he doesn't think it is working. How should the nurse respond?

Administer antihypertensive

A patient with a chronic spinal cord injury at C3 is admitted to the ER with severe headache and blood pressure of 210/104. Which action by the nurse would be appropriate?

At bedtime

The nurse is preparing to give the first dose of Zosin to a patient who is post op from an aneurysm repair. The nurse is aware that the ideal time to give this medication to prevent adverse effects is which of the following?

To evaluate for atrial thrombi

The nurse is preparing to assist with a cardioversion for a patient with chronic A Fib. The doctor orders a TEE to be done prior to the procedure. The patient asks the nurse why it is needed. The nurse bases her reply on which of the following rationales?

D Dimer

Platelet

PTT

SATA: The nurse is caring for a patient dx with DIC. The nurse checks the STAT labs to see the status of the patient. Which labs would the nurse expect to be abnormal?

Asthma

The nurse is reviewing the health hx of a pt. who is to be prescribed sotalol to control V tach. Which of the following does the nurse recognize as a contraindication to sotalol?

This medication can cause birth defects or fetal death

A pregnant pt. is experiencing gestational HTN and will need an antihypertensive. The pt. states, " My grandmother takes Losartan and her BP is good. Do you think the doctor can prescribe that for me?" How should the nurse respond?